Background: By 2050, sub-Saharan Africa’s (SSA) urban population is expected to grow from 414 million to over 1.2 billion. This growth will likely increase challenges to municipalities attempting to provide access to water supply and sanitation (WS&S). This study aims to characterize trends in access to WS&S in SSA cities and identify factors affecting those trends. Methods: DHS data collected between 2000 and 2012 were used for this analysis of thirty-one cities in SSA. Four categories of household access to WS&S were studied using data from demographic and health surveys – these included: 1) household access to an improved water supply, 2) household’s time spent collecting water, 3) household access to improved sanitation, and 4) households reporting to engage in open defecation. An exploratory analysis of these measures was then conducted to assess the relationship of access to several independent variables. Results: Among the 31 cities, there was wide variability in coverage levels and trends in coverage with respect to the four categories of access. The majority of cities were found to be increasing access in the categories of improved water supply and improved sanitation (65% and 83% of cities, respectively), while fewer were making progress in reducing the amount of time spent collecting water and reducing open defecation (50% and 38% of cities, respectively). Additionally, the prevalence of open defecation in study cities was found to be, on average, increasing. Conclusions: Based on DHS data, cities appeared to be making the most progress in gaining access to WS&S along metrics which reflect specified targets of the Millennium Development Goals. Nearly half of the cities, however, did not make progress in reducing open defecation or the time spent collecting water. This may reflect that the MDGs have led to a focus on “improved” services while other measures, potentially more relevant to the extreme poor, are being neglected. This study highlights the need to better characterize access, beyond definitions of improved and unimproved, as well as the need to target resources to cities where changes in WS&S access have stalled, or in some cases regressed.